The Role of
Intravitreal Triamcinolone Acetonide in AMD Management
Jost B. Jonas, MD
Department of Ophthalmology, Medical Faculty
Mannheim of the Ruprecht-Karls-University, Heidelberg, Germany
Within the last five years, the intraocular
injection of medications as a treatment modality for posterior segment diseases
has increased exponentially. Intravitreal injection of triamcinolone acetonide
has been used for the treatment of intraocular edematous, proliferative and
neovascular diseases such as diabetic macular edema, macular edema associated
with retinal vein occlusion, proliferative diabetic retinopathy, uveitis
including sympathetic ophthalmia, pre-phthisical chronic ocular hypotony, and
exudative age-related macular degeneration (AMD).(1) When
photodynamic therapy was demonstrated in randomized clinical trials to have a
beneficial effect for the treatment of predominantly classic subfoveal
neovascularization,(2) an evidence-based therapy was not available
for all other types of exudative AMD. Based on findings from experimental
studies, as well as a randomized study in patients with occult subfoveal
neovascularization by Ron Danis and colleagues,(3) intravitreal
triamcinolone was increasingly used for the treatment of exudative AMD if
photodynamic therapy could not be applied. Case series, non-randomized
comparative investigations, and intra-individual inter-eye comparisons of
patients with unilateral treatment and bilateral disease suggested that
intravitreal triamcinolone was associated with better visual results than the
natural course of minimally classic and occult lesions associated with AMD.(1)
In contrast, in a randomized study by Mark Gillies
including patients with
subfoveal neovascularization with any classic component,
intravitreal triamcinolone acetonide was not
associated with a better visual outcome compared to no therapy.(4)
Intravitreal triamcinolone was used more frequently for the treatment of
exudative AMD when it was combined with verteporfin-associated photodynamic
therapy, since case series showed an
improvement in visual acuity in most of the treated patients and since the
improvement in vision was maintained during a two-year follow-up period with
relatively low retreatment numbers.(5)
Side effects such as increased intraocular pressure in about 40% of patients and
cataractogenesis in combination with relatively meager results in terms of
vision improvement led to an almost complete replacement of intravitreal
triamcinolone monotherapy by intravitreal injections of anti-vascular
endothelial growth factor (VEGF) drugs, such as pegaptanib, ranibizumab and
bevacizumab. Compared with intravitreal triamcinolone monotherapy, these anti-VEGF
drugs were associated with markedly better improvement in visual acuity in
patients with exudative AMD. Since the effect duration of these intravitreally
injected anti-VEGF drugs is limited to several weeks, further research of
combination treatment strategies (such as the combination of anti-VEGF agents
with intravitreal triamcinolone) is needed to investigate whether intravitreal
steroids such as triamcinolone acetonide may re-gain a role in the treatment of
AMD.
References
1. Jonas
JB. Intravitreal triamcinolone acetonide: a change in
a paradigm. Ophthalmic Res 2006;38:218-245.
2.
Miller JW, Schmidt-Erfurth U, Sickenberg M, et al. Photodynamic therapy with
verteporfin for choroidal neovascularization caused by age-related macular
degeneration: results of a single treatment in a phase 1 and 2 study. Arch
Ophthalmol 1999;117:1161-73. Erratum in: Arch Ophthalmol 2000;118:488.
3. Danis
RP, Cuilla TA, Pratt LM, Anliker W. Intravitreal triamcinolone acetonide in
exudative age-related macular degeneration. Retina
2000;20:244-250.
4.
Gillies MC, Simpson JM, Luo W, et al. A randomized
clinical trial of a single dose of intravitreal triamcinolone acetonide for
neovascular age-related macular degeneration: one-year results. Arch Ophthalmol
2003;121:667-673.
5.
Augustin AJ, Schmidt-Erfurth U. Verteporfin therapy combined with intravitreal
triamcinolone in all types of choroidal neovascularization due to age-related
macular degeneration. Ophthalmology 2005;113:14-22.
Corresponding author: Dr.
Jost B. Jonas, Universitäts-Augenklinik, Theodor-Kutzer-Ufer 1-3, 68167
Mannheim, Germany; Phone: **49-621-383-2242; Fax: **49-621-383-3803; e-mail:
Jost.Jonas@augen.ma.uni-heidelberg.de